HomeMy WebLinkAbout2025-00045175 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 0110110011 001111*000111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00368615
u, 1 U21 1 1 1 U11 O U216 U, 1 1_12 1 U, 1 U2 1 4 12 u1 2 u2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00045175 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 07 13 2025 IMAM ❑YES ®NO U1
W HIGHLAND AVE Elgin00:10
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W N EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD DO
U2 —I
IgI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
f4T TOWED U1
Gutierrez. Ismael.J. Chevrolet Cobalt 2005 00-NONE 11 • 12 -0 DUE TO CRASH ® ❑ E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
M 9 4 ❑Y SYSTEM❑LINK VEH. O AT O
ON ENGAGED 99-UNKNOWN 9 16-TOP() `Distraction Value 9 ALGN =
r •
F_ FIRST CONTACT 3 7 _
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 it COM VEH 0 0 1 n
,--_;_O6 •u Yes.See Sidebar U1 0
Z ELGIN IL 60120 0 1 0 IL REAR
TELEPHONE
IL D 1 G 1 AL12F757621682 Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Carla Dama. Ismael Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑r uv 0 NOV ❑DV
!2 0 0 6 Nissan Maxima 2006 00-NONE 11 12'.--1 DUE TO CRASH ❑ 2 x
o - 13-UNDERCARRIAGE FIRE 0 El U2
Ti
M 9 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑LINK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O 1 6 i',.4 COM VEH 0 ® Ut W
F,,, FIRST CONTACT 9 O7 _, _6 •Iryes.See Sidebar C
ELGIN IL 60123 0 1 0 ER33937 IL 2026 I 4 (I)
IL D 1 N4BA41 E16C854547 STATE FARM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 0520389-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
Ei N 1 ® 11 1 07,13 /2025 00 10 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 50 04 1 / ❑PM ❑Construction *
1
Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Gutierrez. Ismael.J. 11-601 752181 / ! 0 PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM•
El Utility
t 2 El ARREST NAME Gutierrez. Ismael.J. 3-707 752177 071 13 12025 00 11 MPM ElUnknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 05
1505-Caliendo.Anthony 601 08 ,28 12025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -' -' I. INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or C
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- <_--------•i
, - } } } transporting employees in the course of their employment(example:employee X
TI I vomya„mp„ transporter-usually a van type vehicle or passenger car):or CO-- - - - 4
- I. I- } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
�+ for direct compensation(example:large van used for specific purpose):or— — O
L., t i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m I- `-----`-----I ^
-
' I placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME
Not To Scaie ! I ri i. ':. i... -4-N ADDRESS
T.
CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate El Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE